Preventing Resident-to-Resident Aggression in Dementia Eilon Caspi Ph.D. Geriatrics & Extended Care Data & Analyses Center, Providence VAMC Annual NICE
Preventing Resident-to-Resident Aggression in Dementia Eilon
Caspi Ph.D. Geriatrics & Extended Care Data & Analyses
Center, Providence VAMC Annual NICE Knowledge Exchange, Toronto,
May 21, 2014 Dwayne E. Wall
Slide 2
Sponsored by Institute for Life Course and Aging, University of
Toronto
Slide 3
The Role of Language White Paper: Dementia Care: The Quality
Chasm (2013). National Dementia Initiative. Caspi, E. (2013). Time
for change: Persons with dementia and behavioral expressions, not
behavior symptoms. JAMDA, 14(10), 768-769.
Slide 4
RRA in dementia is over a century-long problem "when walking
about groped the faces of other patients, and was often struck by
them in return." Source: Lock (2013). The Alzheimers Conundrum:
Entanglements of Dementia and Aging. Princeton University Press.
Auguste D. Year: 1901
Slide 5
Quotations (Caspi, 2013) This is a matter of serious concern.
It happens very often and will be fatal. Resident Some of them
really get afraid of him, and when I say get afraidI mean get
afraidWhen they see him coming, they dont want to sit in the dining
room CNA I am afraid that he will hurt someone when we dont see
itespecially someone frail whom he can take down with one blow.
CNA
Slide 6
Serious Consequences Negative consequences for: Target resident
Exhibitor Witnesses Staff Family members Visitors LTC residence
Society + Substantial cost implications
Slide 7
Serious Consequences Target Residents Psychological:
frustration, anger, anxiety, fear, sadness, depression, social
isolation, avoidance of activities and dining room Physical:
Injuries and accidents: falls, dislocations, bruises or hematomas,
reddened areas, fractures, lacerations, abrasions (Shinoda-Tagawa
et al. 2004) Deaths (numerous reports in the media) Frank
Piccolo
Slide 8
Guiding Principles Aggressive behaviors in persons with
dementia are usually expressions of unmet needs (Whall &
Kolanowski, 2004; Sifford, 2010) They usually have meaning,
purpose, and function to the resident Attempts at communication
Attempts at gaining control over threatening/unwanted situation
Attempts at preserving dignity Barometers for tolerance to
stressful stimuli (Smith et al. 2004)
Slide 9
Unmet Needs They have the same needs as we do The difference?
They have difficulty identifying or meeting their needs or
expressing them verbally They become distressed for the same
reasons we do The difference? They are less and less able to
tolerate and cope with the stress in their environment
Slide 10
Slide 11
Responsive Behaviors Definition A response to something
negative, frustrating, or confusing in the persons environment It
places the reasons or triggers for challenging behaviors outside,
rather than within, the individual, thereby recognizing that
problems in the social and physical environment can be addressed
and changed Lisa Loiselle (2004) - Murray Alzheimers Research &
Education Program
Slide 12
Guiding Principles The cumulative effects of multiple factors
intersect with the residents cognitive and other impairments
leading to RRA Aggressive behaviors tend to manifest in patterns
(e.g. time of day, location, events, people, things) A small number
of residents account for a large portion of RRA (Malone et al.,
1993; Negley & Manley, 1990; Allin et al. 2003; Almvik et al.
2007; Bharucha et al. 2008)
Slide 13
Guiding Principles The best way to handle aggressive behaviors
is to prevent them from occurring in the first place (Judy Berry,
Lakeview Ranch) Understand the meaning of the sequence that led to
the aggressive behavior (Cohen-Mansfield et al. 1996) Situational
triggers and early warning signs can be identified in the majority
of RRA episodes (Caspi, 2013; Snellgrove, 2013) Triggers may be:
Remote, immediate, internalor any combination of these
Slide 14
Guiding Principles Interdisciplinary assessment is critical for
identifying contributing factors, causes & triggers the basis
for individualized intervention A comprehensive, proactive, &
well-coordinated intervention must be applied consistently at
multiple time points and levels of the organization to achieve a
sustainable prevention effect Commitment by everyone at all levels
of the organization and beyond
Slide 15
Anticipatory Care Approach Actions taken before the usual time
of onset of a particular need or problem in order to prevent or
moderate the occurrence of the problem (Kovach et al. 2005)
Slide 16
Interventions are more effective when implemented before peak
level of agitation Smith et al. (2004)
Slide 17
Case Example (Catherine Unsino) Every day at 6:00pm a resident
becomes aggressive (slamming drawers & throwing books across
room) and screams: I need a line, I need a line, I need a line.
Staff couldnt understand what he meant Life history: He was a
traveling businessman who used to call his wife every night to tell
her Good night and I love you. Intervention: Staff let him call his
wife before 6:00pm Outcome: The behavior was eliminated, he was
calm, and psychotropic medications were avoided
Slide 18
Walking Group Intervention (Holmberg, 1997) Concerns about
wandering during early evening hours causing RRA on dementia unit
Intervention: Immediately after dinner volunteers led 30-minute
walking group for 3 consecutive days Compared to 4 days without
walking groups Outcome: Reduction of 30% in aggressive incidents
during 24 hours after walking (RRA & resident-staff)
Slide 19
Case Example (Johnston 2000) Horticulture group activity in VA
Medical Center a group of veterans are transplanting blooming
tulips Mr. W became pale, tremulous, agitated, hyperventilated, and
assaulted another resident He was physically restrained and
returned to the locked unit Conversation revealed: Became
distressed on seeing the tulips Life history: During his army
service in WWII (1943-5) several of his platoon were killed after
being cornered in a tulip field
Slide 20
Case Example (Moniz-Cook et al. 2001) Jack, 89 years old, late
stage Alzheimers Aggressive toward staff, residents, visitorsbut
cant verbalize his concern Observation (2-month): Total of 19
episodes Usually: Grabbing, pulling & shaking others Staff were
unable to identify the trigger
Slide 21
Case Example (Cont.) Observation (4-day): Only one attack on
the psychologist as she put on her green coat prior to leaving Life
history: Jack belonged to a fishing community where the color green
was believed to be unlucky b/c of its association with death
Intervention (20-month): No green clothes policy Outcome: Only 1
episode when a new staff didnt redirect Jack from the room where a
visitor dressed in green Behavior reframed: Jack was trying to
protect others from the harmful effects of the green clothes
Slide 22
Reflection Question If you had the perfect pill that could take
away these behaviorswithout side effectswould you give it to these
peopleeven when you know that the pill will not address the unmet
needs that cause the behavior? Professor Cohen-Mansfield, as cited
by Dr. Allen Power
Slide 23
Slide 24
Contributing Factors, Causes, & Triggers Permission to use
the picture was received from JDC-ESHEL (Photographer Moti
Fishbain)
Slide 25
Contributing Factors, Causes, & Triggers Residents
Background Factors Male Prior occupation Pre-morbid personality
Aggression prior to admission Poor quality of relationships
Depression bvFTD; VaD; Early-onset AD; CTE (D Pugilistica), TBI,
Korsakoff S Mental illness (e.g. Schizophrenia, Bipolar) PTSD
Delusions and hallucinations Substance abuse
Slide 26
Contributing Factors, Causes, & Triggers
Physiological/Medical & Functional Factors Pain Constipation
UTI Incontinence Memory loss (short-term memory deficit)
Visuospatial disorientation (Wayfinding difficulty) Impaired
ability to communicate Sleeping problems / Fatigue Hearing/vision
loss
Slide 27
Contributing Factors, Causes, & Triggers Situational Causes
and Triggers Frustration Boredom Invasion of personal space Seating
arrangement Intolerance of anothers behavior Repetitive speech
Competition for resources Unwanted entry into bedroom Conflicts b/w
roommates Racial/ethnic comments/slurs
Slide 28
Contributing Factors, Causes, & Triggers Factors in
Physical Environment Noise Crowdedness Lack of privacy and private
away areas Inadequate landmarks/signage (wayfinding difficulties)
Hallways (too narrow; dead ends) Inadequate lighting & glare
Too cold or hot Indoor confinement TV Elevators
Slide 29
Contributing Factors, Causes, & Triggers Staff and
Organizational Factors Low staff-resident ratio Lack of training
(Dementia care & RRA-specific) Inappropriate approaches
(Elderspeak) Inattentiveness to early warning signs & triggers
Burnout Underreporting Poor quality of documentation/assessment
Tense relationships Staff-resident language/cultural mismatch
Slide 30
Prevention and De-escalation Strategies Strategies at
regulatory/oversight, emergency, and law enforcement levels
Procedures & strategies at organizational level Proactive
measures Immediate strategies during episodes Post-episode
strategies
Slide 31
Strategies at the regulatory/oversight, Emergency, & Law
Enforcement Levels Address RRA in regulations Require adequate
number of hours of activities per day Increase state inspectors
focus on RRA Ombudsman (training, reporting standards, complaint
categories) NH Compare should track verbal, physical, sexual RRA
Require by law to inform residences on paroled offenders Increase
involvement of Medicaid Fraud Control Units
Slide 32
Strategies at the regulatory/oversight, Emergency, & Law
Enforcement Levels Improve Coroner/Medical Examiner practices
(workloads; training; data repository) Improve practices related to
death certificates Increase collaboration b/w police & state
survey agencies Train first responders (medical emergency staff
& law enforcement personnel)
Slide 33
Need for Adequate Reimbursement Address inadequate
reimbursement mechanism (e.g. disincentive to prevent RRA): In the
current reimbursement system you get more money if someones
behavior is out of control. So whats the incentive to do it? Judy
Berry, Lakeview Ranch Non-pharmacological interventions should be
reimbursed in the manner pharmacological interventions are
(Cohen-Mansfield, 2000)
Slide 34
Consensus Guidelines (Howard et al. 2001; American Geriatrics
Society, 2003) The 1 st line of treatment of behaviors in nursing
home residents with dementia is non-pharmacological (personalized)
approach Unless there is an immediate risk for harm or when the
person is in severe distress Psychotropic medications are: * Not
effective for most PwD and may cause harm * They mask the need
underlying the behavior * Very expensive
Slide 35
Serious Mental Illness The reality: Many with serious mental
illnesses (e.g. Schizophrenia) live in nursing homes Strengthen
collaboration b/w mental health centers/specialists & LTC homes
Develop specialized housing solutions for persons with serious
mental illness (Harvey, 2005; Leff et al. 2000)
Slide 36
MDS 3.0 Add RRA-specific questions to MDS 3.0 Currently, it is
not possible to identify the target of aggressive behaviors
(Section E Behavior) Major missed opportunity to shed light on RRA
Caspi, E. (2013). M.D.S. 3.0 A giant step forward but what about
items on resident-to-resident aggression? JAMDA, 14(8),
624-625.
Slide 37
Procedures & Strategies at Organization Level Employ the
right people & support them!!! Train staff in: AD-specific
communication techniques (Feil & de Klerk-Rubin, 2012)
RRA-specific recognition and prevention strategies (Teresi et al.
2013) Address RRA in Policies and Procedures Maintain adequate
staff-resident ratio Recruit volunteers to strengthen supervision
Promote empathy and compassion b/w residents Hold Resident &
Family Council Meetings
Slide 38
Procedures & Strategies at Organization Level Set realistic
admission criteria Conduct pre-admission behavioral evaluation Put
preventive measures for newly admitted residents (e.g. Buddy
System, Lakeview Ranch, MN) Improve roommate selection (monitor
existing assign.) Strengthen reporting policy & quality
documentation Collaborate and seek input from family members
Slide 39
Proactive Measures Be constantly alert. Watch residents
vigilantly! Be proactive! Stop the vicious cycle of reactivity
(Zgola, 1999) Regularly move around the unit (avoid tendency to
congregate) Remove or secure objects used as weapons Physical
environment (address described above factors & triggers)
Identify and address early warning signs of distress (Caspi, 2012)
Assess risk of imminent violence using Brset Violence Checklist
(Almvik & Woods, 1999; Almvik et al. 2007) Proactively identify
& address unmet needs before they escalate...
Slide 40
Proactive Measures Proactively identify and address physical
discomfort/medical needs (e.g. Discomfort Scale (DS-DAT) Hurley et
al. 1992) Recognize & treat pain (assessment tools in LTC
residents with dementia Hadjistavropoulos et al. 2010) Be informed
about previous altercations Work as a team! Enhance communication
b/w staff and managers Build close trusting relationships with
residents Implement consistent assignment (staff-resident) Know the
life history of residents (20 reasons) (Caspi, 2014a) Find out what
makes him/her lose temper/become angry
Slide 41
Close Trusting Relationship Permission to use: this image
received from Ofir Ben Natan, ESHEL, Israel
Slide 42
Proactive Measures Structured/consistent routine (but be
flexible) Engage residents in meaningful activities Monitor content
on TV Ensure managers present (esp. evenings; weekends) Train staff
in non-violent self-protection techniques Install emergency call
buttons & use hand-held radios Use assistive technology (e.g.
Vigil Dementia System) (Kutzik et al. 2008) Care-Media technology
(Bharucha et al. 2006)
Slide 43
Meaningful Activities [ADD PICTURES OF ENGAGEMENT IN
ACTIVITIES] Permission to use: this image received from Ofir Ben
Natan, ESHEL, Israel
Slide 44
Experts Opinion Activities are the main weapon against behavior
difficulties and violent behavior Dr. Paul Raia If a person with
dementia is engaged in a meaningful activity, the person can not
simultaneously be exhibiting problematic behavior Dr. Cameron Camp
Unless theres Unmet medical need, fatigue, or remote trigger from
the past. Something negative or irritating in the physical
environment (TV content, glare, or crowding) could also trigger
behavioral expressions during activities. Activities that are not
planned well or not delivered professionally and lack of skilled
guidance, cueing, and encouragement may also contribute to anxiety
and behavioral expressions.
Slide 45
Structured Activities Music therapy / Music-based activities /
Listening to favorite music (Film: Alive Inside) Physical activity
(Exercise / Taking a walk together / Dancing) Art Therapy (water
colors) / Simple crafts (clay; wood craft); Museum visits (MoMA
Alzheimers project; ARTZ) Aroma Therapy / Massage Therapy (English
Rose Suites) Therapeutic gardening (Planting flowers or herbs on a
raised flower bed) Pet therapy (Animal-assisted therapy) (Lakeview
Ranch) Reconnecting with nature / Bird watching (e.g. Bird Tales
program) / Fishing / Visiting the zoo / botanical gardens Spiritual
/religious activities
Slide 46
Study on Activities in LTC Residences (Casey, in press) 36 LTC
homes; 406 residents; 82% with dementia Compared structured
activity time with unstructured time Findings Unstructured time
More disengaged (doing nothing), anxious, agitated, sad...
Structured activity time Less anxious, more engaged, and
happier
Slide 47
Left on her own and becomes anxious and agitated A study in two
dementia units on a group of 12 residents with the highest levels
of behaviors (Caspi, 2014b) Findings: The residents developed
negative emotional states and various behaviors when left alone for
too long Became worried, restless, frustrated, anxious, fearful,
sad, irritable, angry, and aggressive Hygiene problems & risky
behaviors When engaged in meaningful activities, they had much less
negative experiences and much more positive experiences
Slide 48
Experts Opinion If I have one message about dementia-related
behaviorit is: Assume people are scared. They live in a world that
doesnt make sense to them. They dont know who to trust and they are
looking for reassurance that they are in the right place, doing the
right thing, and that someone knows how to find them. That explains
a lot of the behaviors. If you think about that each time you see
someone who looks like they are behaving uncharacteristically or
aggressively, youll do fine. Professor Lisa Gwyther, Alzheimers
Research Center, Duke University Source: HealthCare Interactive:
Online Dementia Training
Slide 49
Permission to use: this image received from Ofir Ben Natan,
ESHEL, Israel
Slide 50
Permission to use the image received from Dr. Cathy Greenblat,
author of the book: Love, Loss, & Laughter: Seeing Alzheimers
Differently (2011
Slide 51
Permission to use the image received from Dr. Cathy Greenblat,
author of the book: Love, Loss, & Laughter: Seeing Alzheimers
Differently (2011
Slide 52
Permission to use the image received from Dr. Cathy Greenblat,
author of the book: Love, Loss, & Laughter: Seeing Alzheimers
Differently (2011)
Slide 53
The reality is that LTC residents are not engaged in meaningful
activities most of the time As shown in research: Cohen-Mansfield
et al. (1992) Burgio et al. (1994) Schreiner et al. (2005) Wood et
al. (2005)
Slide 54
A wise lawyer will first approach the activity director and
ask: How did you engage the resident in a way that would have
prevented the violence/injury against my client? Dr. Paul Raia
Slide 55
Immediate Strategies During Episodes The behavior can not be
changed directly, only indirectly by changing either our approach
or the persons physical environment Dr. Paul Raia
Slide 56
Immediate Strategies During Episodes Engage in a swift,
focused, decisive, firm, and coordinated intervention (Soreff,
2012) Immediately defuse chain reactions (Anxiety is contagious!)
Redirect resident(s) from the area Offer the person to take a walk
together Distract/divert to a different activity / change the
activity Refocus/switch topic to his/her favorite conversation
topic Position, reposition, or change seating arrangement
Slide 57
Immediate Strategies During Episodes Physically separate
residents Avoid conversations in loud/crowded places Slow down!
Never approach from behind/side Usually from the front Establish
eye contact (unless threatening/culturally inappropriate) If he
starts to walk away, dont try to stop him right away (Berry, 2012)
Maintain a safe distance (slightly beyond striking range) Speak at
the level of the eyes Speak withnot at the resident
Slide 58
Immediate Strategies During Episodes Stay calm! They will
mirror your emotional state (Sturm et al 2013) and respond to the
unspoken (your body language & tone of voice) Be sincere. Many
with dementia are able to detect insincerity Avoid smiling during
tense episodes Be firm and direct (rather than angry or irritated)
Identify & address underlying needs behind the behavior Use
short, simple, familiar words/sentences & one-step directions
Never ignore the emotions of a resident Encourage expression of
feelings (fear; anger; frustration) but in a safe location...
Slide 59
Immediate Strategies During Episodes Encourage a compromise
Save face Never argue, reason, correct, or criticize a resident
with dementia Acknowledge & agree even if he/she is incorrect
(unless unsafe) Validate the subjective truth, internal reality,
& feelings of the person, no matter how illogical, chaotic, or
paranoid... (Feil & de Klerk-Rubin, 2012) Avoid Reality
Orientation (in mid-to-late stage Alzheimers) Avoid questions that
challenge the short-term memory Listen to feelings, not facts;
Respond to emotions, not behavior Turn negatives into positives;
Avoid using words: No & Why?
Slide 60
Immediate Strategies During Episodes Never command/demand.
Instead ask for their help (Berry, 2012) Provide frequent
reassurance; Apologize sincerely Ask the person for permission It
is (usually) not intentional. Try not to take it personally If what
you are doing is not working, STOP! Back off Give the person some
space and time. Decide of what to do differently. Try again! (Teepa
Snow). Dont leave resident(s) alone when unsafe! Seek assistance
from co-workers (esp. those resident trusts) Be consistent in
approach (across staff, shifts, & weekends) Notify
interdisciplinary team and physician re episodes Promote
restraint-free care environment (Flaherty, 2004; Wang & Moyle,
2005; Mhler et al. 2011; Tilly & Reed, 2006)
Slide 61
Post-Episode Strategies Reassurance, reassurance, reassurance!
De-briefing procedures and meetings (360-degree approach) Document
the sequence of events & triggers (Behavior Log C aspi, 2013)
Seek emotional support from a trusted co-worker/supervisor Consult
with nurse/physician (first aid; evaluate medical cause; change in
meds) Inform & consult with family re episode and
psychological/physical state Evaluate need for change in seating
arrangement or bedroom/roommate In extreme circumstances (e.g.
potential for immediate harm), consider transfer to psychiatric
hospital / neurobehavioral unit for evaluation Provide detailed,
reliable, and timely written report on RRA episodes as required in
the regulations governing your residence
Slide 62
Assessment is Key Comprehensive Interdisciplinary
Person-directed / Whole person Life course perspective Needs-based
Persistent
Slide 63
Implement: Assessment-based Anticipatory Care Approach Toolkit:
Recognizing Early Warning Signs (Caspi, 2012) Rating Anxiety in
Dementia (RAID) scale (Shankar et al. 1999) Discomfort Scale in
Dementia of Alzheimers Type (Hurley et al. 1992) Behavioral Log
(Caspi, 2013) R-REM Instrument (11-item) (Teresi et al. 2013) Brset
Violence Checklist (Almvik et al. 2007) Interdisciplinary Screening
Form (RRA & dementia-specific) (Caspi) Behavior Intervention
Plan Form (Dr. Paul Raia)
Slide 64
You have formed a theory then?
Slide 65
Behavioral Log
DateWhen?Where?Who?Why?InterventionOutcomeSuggestion
_/_/_TimeLocationWho was there? Cause / Trigger Describe
intervention, if any Describe outcome Make a suggestion for future
What? Detailed description of the behavior and what happened
(sequence of events) BEFORE and AFTER the behavior:
______________________________________________________________________
Persistent use of a behavioral log enables to identify patterns,
causes, and triggers the basis for individualized intervention To
receive the full version of the Behavioral Log, please email
me
Slide 66
Will was hitting residents for apparently no reason (Raia,
2011) Keeping a behavioral log showed: The hitting occurred only in
the activity room [Where?] Never at night [When?] Never struck the
same person twice [Who?] Only on sunny days but not on all sunny
days [What?] Only if he sat on one side of the room [Where?] The
sun was glaring in his eyes. He thought the residents were playing
with the light switch [Why?] Intervention: Drawing down a shade
when he is in the room Outcome: Hitting discontinued; Psychotropic
meds avoided
Slide 67
Looking into the future Due to the retirement of the baby
boomers and the estimated growth of elders with dementia, we are
going to see increasing incidence of resident-to-resident violence.
There will be more and more pressure from family members and
advocacy groups to keep the residents safe. Dr. Paul Raia
Slide 68
Closing Quotation The world is a dangerous place; not because
of those who do evil, but because of those who look on and do
nothing. Albert Einstein
Slide 69
Questions Permission to use: this image received from Ofir Ben
Natan, ESHEL, Israel
Slide 70
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D., Roberson, M. J., Stevens, S., et al. (2003). Toward the
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Slide 71
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of recreational activity. Aging and Mental Health, 9(2), 129-134.
Shankar et al. (1999). The development of a valid and reliable
scale for rating anxiety in dementia (RAID). Aging & Mental
Health, 3(1), 39-49. Shinoda-Tagawa, T., Leonard, R., Pontikas, J.,
McDonough, J.E., Allen, D., & Dreyer, P.I. (2004).
Resident-to-resident violent incidents in nursing homes. Journal of
the American Medical Association, 291(5), 591-598.
Slide 73
References (cont.) Sifford, K.S. (2010). Caregiver perceptions
of unmet needs that lead to resident-to-resident violence involving
residents with dementia in nursing homes (Unpublished doctoral
dissertation). University of Arkansas. Smith, M., Gerdner, L.A.,
Hall, G.R., & Buckwalter, K.C. (2004). History, development,
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W.W., Kramer, J.H., Miller, B.L., & Rankin, K.P. (2013).
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Alzheimers disease is associated with temporal lobe degeneration.
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Pillemer, K., & Lachs, M. (2013). A staff intervention
targeting resident-to-resident elder mistreatment (R-REM) in
long-term care increased staff knowledge, recognition, and
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Slide 74
List of Studies on RRA Caspi, E. (2013). Aggressive behaviors
between residents with dementia in an assisted living residence.
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Practice. Published OnlineFirst Sep 4 2013. Castle, N.G. (2012).
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(2007). Resident-to-resident elder mistreatment and police contact
in Nursing Homes: Findings from a population-base cohort. Journal
of the American Geriatrics Society, 55(6), 840-845. Malone, M. L.,
Thompson, L. S., & Goodwin, J.S. (1993). Aggressive behaviors
among the institutionalized elderly. Journal of the American
Geriatrics Society, 41, 853-856. Negley, E.N. & Manley, J.T.
(1990). Environmental interventions in assaultive behavior. Journal
of Gerontological Nursing, 16(3), 29-33. Pillemer, K., Chen, E.K.,
Van Haitsma, K.S., Teresi, J., Ramirez, M., Silver, S., Sukha, G.,
& Lachs, M.S. (2011). Resident-to-resident aggression in
nursing homes: Results from a qualitative event reconstruction
study. The Gerontologist. Advance Access published November 1,
2011.
Slide 75
List of Studies on RRA (cont.) Rosen, T., Lachs, M. S.,
Bharucha, A. J., Stevens, S. M., Teresi, J. A., Nebres, F., &
Pillemer, K. (2008). Resident-to-resident aggression in long-term
care facilities: Insights from focus groups of nursing home
residents and staff. Journal of the American Geriatrics Society,
56(8), 1398-1408. Shankar et al. (1999). The development of a valid
and reliable scale for rating anxiety in dementia. Aging &
Mental Health, 3(1), 39-49. Shinoda-Tagawa, T., Leonard, R.,
Pontikas, J., McDonough, J.E., Allen, D., & Dreyer, P.I.
(2004). Resident-to-resident violent incidents in nursing homes.
Journal of the American Medical Association, 291(5), 591-598.
Sifford-Snellgrove, K.S., Beck, C., Green, A., McSweeney, J.C.
(2012). Victim or initiator? Certified nursing assistants
perceptions of resident characteristics that contribute to
resident-to-resident violence in nursing homes. Research in
Gerontological Nursing, 5(1), 55-63. Sifford, K.S. (2010).
Caregiver perceptions of unmet needs that lead to
resident-to-resident violence involving residents with dementia in
nursing homes (Unpublished doctoral dissertation). U of Arkansas.
Snellgrove, S.Beck, C., Green, A., McSweeney, J.C. (2013).
Resident-to-resident violence triggers in nursing homes. Clinical
Nursing Research, 22(4), 461-474. Teaster, P. B., Ramsey-Klawsnik,
H., Mendiondo, M. S., Abner, E., Cecil, K., & Tooms, M. (2007).
From behind the shadows: A profile of sexual abuse of older men
residing in nursing homes. Journal of Elder Abuse and Neglect,
19(1), 29-45. Zhang, Z., Schiamberg, L., Oehmke, J. et al. (2011).
Neglect of Older Adults in Michigan Nursing Homes. Journal of Elder
Abuse and Neglect, 23, 58-74.
Slide 76
Literature Reviews Rosen, T., Pillemer, K., & Lachs, M.
(2007). Resident-to-resident aggression in long-term care
facilities: An understudied problem. Aggression and Violent
Behavior, 13, 77-87. Rosen, T., Lachs, M.S., & Pillemer, K.
(2010). Sexual aggression between residents in nursing homes:
Literature synthesis of an underrecognized problem. Journal of the
American Geriatrics Society, 58, 1070-1079.
Slide 77
Archival Blog/Center for Prevention of Resident-to-Resident
Aggression in Dementia To access the free resources posted on the
center, please go to: http://eiloncaspiabbr.tumblr.com Understand,
raise awareness, act!
Slide 78
Contact Information Website:
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